1477791606 NPI number — MR. MATTHEW TIMOTHY PORTER M.D.

Table of content: MR. MATTHEW TIMOTHY PORTER M.D. (NPI 1477791606)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477791606 NPI number — MR. MATTHEW TIMOTHY PORTER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PORTER
Provider First Name:
MATTHEW
Provider Middle Name:
TIMOTHY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477791606
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1081 EAST 18TH STREET
Provider Second Line Business Mailing Address:
PO BOX 458
Provider Business Mailing Address City Name:
ROLLA
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65401-8115
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-426-6712
Provider Business Mailing Address Fax Number:
573-426-6723

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
831 LAUREL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROLLA
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65401-3841
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-596-1765
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/26/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  26022 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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